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Portal vein thrombosis – a primer for the general physician

Andrew Thompson
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DOI: https://doi.org/10.7861/clinmedicine.17-5-479
Clin Med October 2017
Andrew Thompson
Musgrove Park Hospital, Taunton, UK
Roles: Consultant physician and trust thrombosis lead
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Editor – I was surprised to find the authors of ‘Portal vein thrombosis – a primer for the general physician’ strongly advocated an extensive search for thrombophilic conditions.1 While these conditions undoubtedly increase the risk of portal vein thrombosis, the question is does knowledge of these mutations alter the subsequent management of the condition or the duration of treatment?

There may be a justification in testing for some thrombophilic conditions, eg identifying myeloproliferative disorders with the JAK2 mutation, and some thrombophilias convey a higher risk of recurrence than others,2 but there is certainly little justification in screening for factor V Leiden and prothrombin gene mutations.

The 2012 National Institute for Health and Care Excellence guidelines for venous thromboembolism (VTE), which are surprising supportive of thrombophilia screening, do not include factor V Leiden and the prothrombin mutation as they do not increase the risk of recurrence to a clinically significant extent.3

In contrast, the 2010 British Society of Haematology guidelines state ‘testing for heritable thrombophilia after a first episode of intra-abdominal vein thrombosis has uncertain predictive value for recurrence. Grade C evidence – as no studies have investigated how the finding of a heritable thrombophilia should influence management’.4

Analysis of the large multiple environmental and genetic assessment study showed that testing for inherited thrombophilia did not reduce recurrence of venous thrombosis.5

The American College of Chest Physicians guidelines on VTE, which recommend ongoing anticoagulation after an unprovoked VTE, list thrombophilias among factors that predict risk of recurrence, ‘but not strongly enough to influence recommendations on duration of therapy’.6 And US guidelines have an equally clear message of ‘do not perform thrombophilia testing in patients following an episode of unprovoked VTE’.2

In summary, thrombophilia is commonly evaluated in patients without a clear indication for testing and not only that, but frequently during times when the results may be unreliable.

Conflicts of interest

The author has no conflicts of interest to declare.

  • © Royal College of Physicians 2017. All rights reserved.

References

  1. ↵
    1. Harris M
    , Thachil J. Portal vein thrombosis – a primer for the ­general physician. Clin Med 2017;17:212–9.
    OpenUrlAbstract/FREE Full Text
  2. ↵
    1. Stevens MS
    , Woller SC, Bauer KA, et al. Guidance for the evaluation and treatment of hereditary and acquired thrombophilia. J Thromb Thrombolysis 2016;41:154–64.
    OpenUrl
  3. ↵
    1. National Clinical Guideline Centre (UK)
    . Venous thromboembolic diseases: the management of venous thromboembolic diseases and the role of thrombophilia testing. London: Royal College of Physicians, 2012.
  4. ↵
    1. Baglin T
    , Gray E, Greaves M, et al. Clinical guidelines for testing for heritable thrombophilia. Br J Haematol 2010;149:209–20.
    OpenUrlCrossRefPubMed
  5. ↵
    1. Coppens M
    , Reijnders JH, Middeldorp S, et al. Testing for inherited thrombophilia does not reduce the recurrence of venous thrombosis. J Thromb Haemost 2008;6:1474–7.
    OpenUrlCrossRefPubMed
  6. ↵
    1. Kearon C
    , Akl EA, Comerota AJ, et al. Antithrombotic therapy for VTE disease: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines. Chest 2012;141:e419S–e494S.
    OpenUrlCrossRefPubMed
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Portal vein thrombosis – a primer for the general physician
Andrew Thompson
Clinical Medicine Oct 2017, 17 (5) 479; DOI: 10.7861/clinmedicine.17-5-479

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Portal vein thrombosis – a primer for the general physician
Andrew Thompson
Clinical Medicine Oct 2017, 17 (5) 479; DOI: 10.7861/clinmedicine.17-5-479
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